Effects of switching from omega-3-acid ethyl esters to icosapent ethyl in a statin-treated patient with elevated triglycerides

Comparing the Impact of Prescription Omega-3 Fatty Acid Products on Low-Density Lipoprotein Cholesterol

Elevated levels of triglycerides are associated with pancreatitis and an increased risk of coronary heart disease. Numerous pharmacologic therapies are available to treat hypertriglyceridemia, including prescription omega-3 fatty acids, which reduce triglyceride levels by 20-50%. Available data indicate the omega-3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) may be beneficial for secondary prevention of coronary heart disease. Products containing DHA may increase low-density lipoprotein cholesterol (LDL-C) and, subsequently, coronary heart disease risk. We reviewed prescription omega-3 fatty acid products, of which two-omega-3 acid ethyl esters (OM3EE) and omega-3 carboxylic acid (OM3CA)-contain both DHA and EPA, whereas the other-icosapent ethyl (IPE)-contains EPA only. We identified three retrospective chart reviews and three case reports comparing IPE with OM3EE, whereas two studies compared IPE with placebo. We also reviewed the major studies of OM3EE versus placebo used to gain US FDA approval. LDL-C levels decreased or did not increase significantly in all available studies and case reports in patients receiving the IPE product, with the best data supporting a dose of 4 g per day. The majority of studies only included patients taking IPE concomitantly with statins, but limited data from one study using IPE monotherapy showed a small reduction in LDL-C. Many questions remain regarding IPE, including whether the product reduces cardiovascular events and mortality.

Cardiovascular disease and omega-3s: Prescription products and fish oil dietary supplements are not the same

BACKGROUND AND PURPOSE

Despite achievement of optimal low-density lipoprotein cholesterol (LDL-C) control with statin therapy, patients with elevated triglycerides (TGs) and residual cardiovascular risk are commonly encountered in clinical practice.

METHODS

We present information from completed and ongoing clinical trials examining Rx omega-3s for TG-lowering and omega-3 dietary supplements to highlight important differences affecting patient management for nurse practitioners.

CONCLUSIONS

Rx omega-3s demonstrate robust reductions in TGs and may have a role in reducing residual cardiovascular risk. Products containing docosahexaenoic acid (DHA) may raise LDL-C and should not be substituted for Rx eicosapentaenoic acid (EPA)-only icosapent ethyl, which does not raise LDL-C. Omega-3 dietary supplements (e.g., fish oils containing EPA and DHA) may be used for general health promotion; however, they are not regulated as medications and concerns regarding quality, purity, safety, and variability of content exist. It is important to advise patients that omega-3 dietary supplements are not medications and should not be substituted for Rx omega-3s. Large-scale cardiovascular outcomes studies are underway for Rx omega-3s in statin-treated patients.

IMPLICATIONS FOR PRACTICE

Nurse practitioners can take an active role in reducing residual cardiovascular risk and educating patients about important differences between Rx omega-3s and fish oil supplements.

Lipid effects of switching from prescription EPA+DHA (omega-3-acid ethyl esters) to prescription EPA only (icosapent ethyl) in dyslipidemic patients

OBJECTIVES

Residual cardiovascular risk and persistently elevated triglycerides (TGs) may remain despite statin therapy in patients with dyslipidemia. Prescription omega-3 fatty acid formulations containing docosahexaenoic acid (DHA) and/or eicosapentaenoic acid (EPA) have been shown to reduce TGs and may potentially lower residual cardiovascular risk. However, DHA may raise low-density lipoprotein cholesterol (LDL-C) and compromise treatment goals. Icosapent ethyl (Vascepa®), a high-purity prescription EPA formulation, has been shown to lower TGs and other lipid parameters without raising LDL-C. There are no prospective, randomized, controlled trials of the effects of switching patients from omega-3-acid ethyl esters (Lovaza®), a prescription formulation containing EPA+DHA, to icosapent ethyl.

METHODS

This retrospective chart review included records of high-risk patients aged ≥18 years receiving stable statin therapy for dyslipidemia who had been switched from prescription omega-3-acid ethyl esters 4 g/day to prescription icosapent ethyl 4 g/day and had available laboratory lipid profiles after receiving each for ≥2 months. Lipid assessments were conducted by local laboratories. Patient records were excluded if there were changes in medication or health condition that could affect lipid parameters.

RESULTS

The records of 8 patients (6 women and 2 men; 54-83 years) met eligibility criteria. Following the switch to icosapent ethyl, LDL-C changes ranged from +3.2% to -69.1% (reduced in 7 patients), total cholesterol was reduced in all patients (-3.5% to -44.3%), and TG changes ranged from +32.4% to -59.0% (reduced in 6 patients). Decreases or no changes in non-high-density lipoprotein cholesterol were observed; changes in high-density lipoprotein cholesterol varied. No adverse events related to either product were reported.

CONCLUSION

In this real-world retrospective analysis, switching high-risk statin-treated patients from omega-3-acid ethyl esters to icosapent ethyl resulted in favorable lipid changes. The analysis was limited by the small patient numbers, but lipid results were consistent with randomized controlled trials and previous case series.

Improving lipids with prescription icosapent ethyl after previous use of fish oil dietary supplements

Managing dyslipidemia can be challenging in patients with statin intolerance. We describe the lipid effects of icosapent ethyl 4 g/day (high-purity prescription omega-3 eicosapentaenoic acid) in two coronary artery disease patients with statin intolerance who were self-treating with fish oil dietary supplements. After initiating icosapent ethyl, improvements were noted in the first and second patients, respectively, in total cholesterol (-12%; -21%), LDL cholesterol (-3%; -24%), triglycerides (-34%; -16%), non-HDL cholesterol (-12%; -22%), the omega-3 index (+42%; +8%) and eicosapentaenoic acid levels (+275%; +138%). Icosapent ethyl was well tolerated with no adverse events reported. These cases demonstrated favorable lipid effects with prescription icosapent ethyl treatment that may help optimize the care of high-risk coronary artery disease patients with statin intolerance.

Switching statin-treated patients from fenofibrate to the prescription omega-3 therapy icosapent ethyl: a retrospective case series

Introduction

Patients receiving statin therapy for dyslipidaemia often require treatment with an additional agent to control triglyceride levels. Options for add-on therapy include fibrates and omega-3 fatty acids. This case series describes the effects of switching add-on therapy from fenofibrate to icosapent ethyl (the ethyl ester of the omega-3 fatty acid, eicosapentaenoic acid) on patient lipid profiles.

Methods

This was a retrospective analysis of patient records from a private medical practice in western New York. Statin-treated patients with dyslipidaemia who had been treated with fenofibrate and later switched to icosapent ethyl were selected for analysis. Lipid profiles before and after the switch to icosapent ethyl were compared.

Results

The records of five patients were analysed. All patients had hypertension and were overweight, male, and at high cardiovascular risk. After the switch to icosapent ethyl (treatment duration 3.9–5.8 months), triglyceride levels decreased in four patients, and low-density lipoprotein cholesterol, non-high-density lipoprotein cholesterol, and total cholesterol levels decreased in all patients. High-density lipoprotein levels increased in four patients. Icosapent ethyl was well tolerated.

Conclusions

Switching from fenofibrate to icosapent ethyl as add-on to a statin therapy due to clinical need may provide an option for patients to maintain or improve lipid parameters.